Independent-Contractor-Questionnaire-DWM-Form-6-12-13

Independent Contractor Questionnaire Colby College is requesting the information below in order to determine the appropriate service provider classification employee vs.. independent con

Independent Contractor Questionnaire

Colby College is requesting the information below in order to determine the appropriate service provider classification (employee vs

independent contractor) under federal and state laws and regulations Please complete and return this questionnaire, along with a completed and signed IRS W-9 form to the Department that is seeking to engage your services Thank you.

Name:

Doing Business As (if applicable):

Address: _

Telephone: _

E-Mail Address:

1 Please describe the exact nature of your trade, occupation, profession or business (referred to hereafter as “business”):

_

2 Please indicate how your business is organized:

 Limited Liability Company

3 How long have you been independently engaged in this business? _

4 Did you file a business tax return last year for this business? Yes No If no, why not?

5 Do you have an IRS determination (SS-8) of independent contractor status? Yes No If yes, provide the date:

_

6 Do you have the opportunity to make a profit or loss in this business? Yes No

7 Do you have a substantive investment in facilities, tools, instruments, materials or products for this business? Yes No

If yes, please provide specific examples:

8 Do you advertise this business? Yes No If yes, please provide examples of where you advertise:

9 How many clients did your business work for in the past 12 months? _

a Please provide names and contact numbers of three major customers (other than Colby College) within the past 12 months:

Did client issue a 1099? Yes  No 

Did client issue a 1099? Yes  No  Did client issue a 1099? Yes  No 

10 Do you work for more than one client at a time? Yes No

11 Do you use assistants to help perform your work? Yes No (If yes, answer questions a and b below.)

a Do you personally pay your assistants? Yes No

b Are you responsible for supervising the details of your assistants’ work? Yes No

Service Provider Certification

I hereby certify that all of the information I have provided above is true and accurate I also certify that I am legally authorized to work in the United States

Signature: _ Date: _

Printed Name: _